Recommendations for the Evaluation of Left Ventricular Diastolic Function by Echocardiography: An Update from the American Society of Echocardiography and the European Association of Cardiovascular Imaging

The plasma proteome is linked to echocardiographic parameters and stages of diastolic dysfunction, across the ejection fraction spectrum

INTRODUCTION

This study investigates the interplay between the circulating plasma proteome and echocardiographic parameters in patients across the spectrum of heart failure (HF) (ranging from patients at risk of/with preserved (HFpEF) to reduced (HFrEF) ejection fraction).

METHODS

Data from two cohort studies, HELPFul and Bio-SHiFT, were analyzed. We measured 4210 circulating plasma proteins in a total of 750 patients using SomaScan® proteomics. Echocardiographic parameters in both studies included left ventricular ejection fraction (LVEF) and the ratio of the peak early left ventricular (LV) filling velocity and early diastolic mitral annular velocity (E/e'). In further analyses, we classified patients in left ventricular diastolic dysfunction (LVDD) groups according to the prevailing guidelines.

RESULTS

Out of the 4210 plasma proteins, 21 proteins were significantly associated with E/e' in patients at risk of/with HFpEF, whereas 9 proteins were associated with LVEF. Approximately 43 % (n = 1822) of the proteins showed significant interactions between E/e' and HF subtype. All of these proteins showed weaker associations with E/e' in patients at risk of/with HFpEF compared to the ones with HFrEF. These proteins were related to the extracellular matrix, cellular processes, insulin-like growth factor (IGF) transport, metabolic and catabolic processes. Furthermore, comparisons between LVDD groups and those with normal diastolic function identified 40 proteins associated with grade 2 (top 5: Cystatin C, TMEDA, NT-proBNP, GDF-15 and PXDN) and 198 with grade 3 LVDD (top 5: NT-proBNP, Cystatin C, PXDN, RNasa1, and Factor D).

CONCLUSION

In patients at risk of/with HFpEF, biological processes and pathways showed weaker associations with E/e' compared to patients with HFrEF. Varying pathways identified through proteomics were associated with deterioration of LVDD across the ejection fraction spectrum. Our results are in line with the mechanistic frameworks currently thought to underlie the various types of HF.

Novel automated electronic medical record-based VEST (virtual echocardiography screening tool) algorithm for pulmonary arterial hypertension

BACKGROUND

Pulmonary arterial hypertension (PAH) remains underrecognized and life-threatening due to limited awareness, nonspecific symptoms, and late referral to accredited pulmonary hypertension (PH) centers. The previously validated virtual echocardiography screening tool (VEST) predicts PAH hemodynamics. The objectives of the present study were to determine if the novel automated electronic medical record (EMR)-based algorithm could accurately calculate VEST scores to identify PAH hemodynamics and aid referral to PH specialty care.

METHODS

This study is a retrospective analysis of 4,952 patients who underwent transthoracic echocardiogram (TTE) with tricuspid regurgitation velocity (TRV) ≥2.9 m/s in a hospital with an accredited PH Center of Comprehensive Care. Using the automated EMR-based algorithm, EMR-calculated VEST scores were calculated and compared to manually calculated VEST scores. Automated EMR VEST scores were used to identify those with highest risk for PAH (+3 score). Patients with +3 score were analyzed to determine whether they were evaluated within the accredited PH center or undergone right heart catheterization (RHC), the gold standard for PH diagnosis.

RESULTS

Automated EMR VEST scores were validated with 100% correlation to 60 manual scores. Of 354 patients with +3 score, those that underwent RHC had severe PH, with mean pulmonary artery pressure 48 mm Hg and pulmonary vascular resistance 8.5 Wood units. One hundred and four patients (29.4%) were never referred for specialty PH care, and of these, only 37.5% underwent RHC. In the 250 patients referred to subspecialty PH care, 237 (94.8%) underwent RHC.

CONCLUSIONS

This novel EMR-based automated VEST calculator is a powerful yet simple scoring tool that can capture patients at high risk for PAH, prompting earlier diagnosis and referrals to accredited PH centers to allow for earlier expert care and implementation of medical therapies.

Low chronotropic response in post-myocardial infarction exercise test predicts worse prognosis in patients with preserved or mildly reduced left ventricular ejection fraction

BACKGROUND

Chronotropic incompetence is prevalent in post-myocardial infarction (MI) patients and linked to reduced exercise capacity. However, its prognostic significance and the determination of threshold values for prognosis remain unclear.

METHODS

Ninety-six post-MI patients with left ventricular ejection fraction (LVEF) ≥ 40 % at four weeks post-event were assessed. All underwent combined exercise stress echocardiography and cardiopulmonary exercise testing (CPET-SE). The chronotropic response was expressed as a percentage of the maximal predicted heart rate (%MPHR) at peak exercise. The primary endpoint was a composite of all-cause mortality or unplanned hospitalization for coronary syndromes or heart failure.

RESULTS

Eighty-six patients completed follow-up (median: 4.0 years [IQR 2.0, 5.6]). The median age was 60 years (IQR 53, 65); 67 % were male, 86 % on beta-blockers. The median LVEF was 57 % (IQR 51, 62), and the median peak VO2 was 19 mL/kg/min (IQR 15, 22). Fifteen composite endpoint events, including three deaths, occurred. Multivariate Cox regression showed that %MPHR (HR 0.95, 95 % CI 0.92-0.98) and smoking history (HR 2.8, 95 % CI 1.1-7.4) were associated with the primary endpoint. A %MPHR threshold of 67 % best predicted the primary endpoint (AUC 73 %, PPV 29 %, NPV 95 %, sensitivity 87 %, specificity 55 %). Patients with %MPHR <67 % had significantly more composite endpoint events than those with %MPHR ≥67 % (p = 0.002).

CONCLUSIONS

A chronotropic response below 67 % of the maximal predicted heart rate is a negative prognostic marker in post-MI patients with preserved or mildly reduced LVEF. This threshold may help risk-stratify and guide management in this population.

Establishment and validation of a critical care echocardiography-based predictive model for sepsis-induced cardiomyopathy: A prospective cohort study

BACKGROUND

Integrating echocardiographic parameters for a comprehensive and precise evaluation of sepsis-induced cardiomyopathy (SIC) presents a significant challenge.

RESEARCH QUESTION

To develop a nomogram for the echocardiographic diagnosis of SIC.

STUDY DESIGN AND METHODS

A cohort of 181 septic patients was prospectively enrolled for critical care echocardiography assessments. The cohort was randomly divided into a training dataset (70 %, n = 126) and a validation dataset (30 %, n = 55). The LASSO regression analysis was used to identify key echocardiographic predictors, which were then analyzed using multivariate logistic regression to determine the final diagnostic predictors and establish an echocardiographic model for SIC. A nomogram was developed based on the model, which was evaluated and verified for discrimination, calibration, and clinical utility.

RESULTS

Three key predictors, including left ventricular global longitudinal strain (GLS), early diastolic mitral flow velocity (E), and tricuspid annular plane systolic motion amplitude (TAPSE), were selected from 14 variables to develop a SIC echocardiographic predictive model. The model exhibited a strong discrimination with an area under the curve (AUC) value of 0.879 in the training dataset and 0.888 in the validation dataset. The results of the Hosmer-Lemeshow test further validated the consistency between predicted probabilities and actual outcomes in both datasets. Decision curve analysis (DCA) indicated a substantial net clinical benefit within risk threshold ranges of 5-100 % in the training dataset and 21-100 % in the validation dataset.

CONCLUSION

The nomogram, incorporating GLS, E, and TAPSE, emerged as a reliable non-invasive tool for assessing the risk of SIC.

CLINICAL TRIAL REGISTRATION

The study protocol was registered in the ChiCTR database (Registration No. ChiCTR2200066966; Date of Registration: December 22, 2022).

Youth Blood Pressure and Target Organ Injury Markers: The SHIP AHOY Study

BACKGROUND

Hypertension in adolescence is associated with subclinical target organ injury. We aimed to determine whether different blood pressure thresholds were associated with an increasing number of target organ injury markers in healthy adolescents.

METHODS

A total of 244 participants (mean age 15.5±1.8 years, 60.1% male adolescents) were studied. Participants were divided based on systolic clinic and systolic awake ambulatory blood pressure into low- (<75th percentile), mid- (75th-90th percentile), and high-risk (>90th percentile) groups. The ambulatory blood pressure phenotype was classified as normotensive, white-coat, masked, or sustained hypertension. Target organ injury assessments included left ventricular mass, systolic and diastolic function, and vascular stiffness. A multivariable general linear model was constructed to evaluate the association of different participant characteristics with higher numbers of target organ injury markers.

RESULTS

A total of 31.2% of participants had 1, 11.9% 2, 3.7% 3, and 0.8% 4 target organ injury markers. The number of target organ injury markers increased according to the risk groups: the percentage of participants with >1 marker in the low-, mid-, and high-risk groups was 6.7%, 19.1%, and 21.8% (P=0.02) and 9.6%, 15.8%, and 32.2% (P<0.001), based on clinic and ambulatory blood pressure, respectively. Participants with white-coat (23%), masked (35%), and sustained hypertension (32%) were more likely to have >1 target organ injury marker than normotensives (8%, P<0.001). The results were unchanged in multivariate analysis.

CONCLUSIONS

High clinic and ambulatory blood pressure values, as well as ambulatory blood pressure phenotypes (white-coat, masked, and sustained hypertension), were independently associated with an increasing number of subclinical cardiovascular injury markers in adolescents.

Prognostic value of the HFA-PEFF and H(2) FPEF scores for clinical outcomes in patients with coronary artery disease and preserved ejection fraction

Background

Coronary artery disease (CAD) is a significant risk factor for heart failure with preserved ejection fraction (HFpEF). While the HFA-PEFF and H2FPEF scoring systems were developed to aid in the diagnosis of HFpEF, their predictive performance in patients with CAD remains underexplored.

Methods

This single-center retrospective cohort study included patients who underwent drug-eluting stent implantation between January 2018 and October 2022. The study's primary endpoint was a composite outcome of all-cause mortality and heart failure hospitalization during follow-up. Kaplan-Meier survival curves were used to evaluate time to adverse events, and differences between groups were analyzed using the log-rank test. Cox proportional hazards regression was applied to assess the independent predictive value of the HFA-PEFF and H2FPEF scores for adverse outcomes.

Results

The HFA-PEFF score categorized 65.7 % of patients as intermediate, 25.1 % as high, and 9.2 % as low probability for HFpEF. The H2FPEF score placed 77.3 % in the intermediate group, 19.3 % in the low, and 3.4 % in the high-probability group. The median follow-up period was 29 months. Adjusted Cox proportional hazard regression revealed the HFA-PEFF score was significantly associated with the composite endpoint of all-cause mortality and heart failure hospitalization (HR: 1.33, 95 % CI:1.07-1.65). Each point increase in the HFA-PEFF score raised heart failure hospitalization risk by 26 % (HR:1.26, 95 % CI: 1.05-1.51). In contrast, the H2FPEF score did not show a significant association with adverse events.

Conclusions

The HFA-PEFF score demonstrated superior prognostic value for predicting adverse outcomes in CAD patients with preserved ejection fraction compared to the H2FPEF score.

Assessment of hemodynamic disturbances and impaired ventricular filling in asymptomatic fontan patients: A 4D flow CMR study

Background

The Fontan procedure is a surgical intervention designed for patients with single ventricle physiology, wherein the systemic venous return is redirected into the pulmonary circulation, thereby facilitating passive pulmonary blood flow without the assistance of ventricular propulsion. Consequently, long-term follow-up of individuals who have undergone the asymptomatic Fontan procedure is essential.

Objectives

The aims of this investigation were to: 1) examine the impact of flow components and kinetic energy (KE) parameters on hemodynamic disturbances in asymptomatic Fontan patients and control group; 2) Assess left ventricular diastolic dysfunction through the analysis of 4D flow parameters across different Fontan sub-groups; 3) Compare intracardiac flow parameters among Fontan sub-groups based on morphological features of the left ventricle (LV) and right ventricle (RV).

Methods

Twenty-five Fontan patients (mean age: 10 ± 3 years, male/female: 15/10) and fourteen control subjects (mean age: 10 ± 2 years, male/female: 8/6) were recruited retrospectively for the study. The Fontan patients were further categorized into three groups based on their ventricular function: left ventricular (LV), right ventricular (RV), and biventricular (BiV). Each participant underwent cardiovascular magnetic resonance (CMR) imaging, including cine and 4D flow sequences on a 3.0 T scanner. Ventricular flow components and KE were assessed using 4D flow. The study utilized cine images to analyze cardiac function and inter-ventricular mechanical dyssynchrony. Echocardiography evaluated functional ventricular diastolic dysfunction.

Results

Fontan patients had a higher median functional single ventricle (FSV) residual volume compared to controls (28 % vs. 23 %, P = 0.034), with lower median FSV direct flow (32 % vs. 40 %, P = 0.005) and delayed ejection flow (17 % vs. 24 %, P = 0.024). The parameters of FSV normalized to the ventricular end-diastolic volume (KEiEDV) were found to be significantly lower in Fontan patients (all P < 0.05). In both left ventricle (LV) and biventricular (BiV) Fontan subgroups, direct flow was identified as an independent predictor of LV diastolic dysfunction (AUC=0.76, Sensitivity=86 %, Specificity=70 %). Furthermore, residual volume and E-wave KEiEDV were observed to be significantly different between LV and right ventricle (RV) Fontan subgroups.

Conclusions

The altered flow pattern and reduced kinetic energy observed in Fontan patients may indicate hemodynamic disturbances and compromised ventricular filling. Reduced direct flow is associated with LV diastolic dysfunction in LV and BiV Fontan subgroups. Systemic LV exhibited a more efficient intracardiac flow pattern compare with systemic RV in Fontan patients.

Strain rate during isovolumic relaxation as a prognostic biomarker for long-term cardiovascular morbidity and mortality: an exploratory study on a general population

AIMS

Left ventricular (LV) strain rate (SR) during early relaxation correlates with LV filling pressures and has been assessed as a prognostic biomarker in several cardiac diseases. Conversely, even though LV SR during isovolumic relaxation (SRIVR) is more strongly related to invasive measurements of LV diastolic function, to date, studies on the role of SRIVR in the long-term prognosis assessment are lacking. Thus, the goal of this study was to assess the potential additive prognostic value of SRIVR on top of conventional cardiovascular risk factors in a general population.

METHODS

657 subjects (mean age 51.6y; 47.6% males) were included in this study and, besides clinical and standard echocardiographic assessment, tissue Doppler imaging (TDI)-based SR was measured during IVR (SRIVR), early diastole (SRe), and atrial contraction (SRa) in the mid-segment of the inferior, inferolateral, lateral, and septal wall of the LV.

RESULTS

During the follow-up period (median 12.1 years), the total number of major adverse cardiac events was 85 (13.4%). Overall, after adjustment for known cardiovascular risk factors and important echocardiographic indices in a multivariable-adjusted Cox regression model, SRIVR of the inferolateral wall (SRIVRinflat) remained an independent predictor of fatal and nonfatal cardiac events (HR: 1.49, p = 0.016), along with GLS (HR: 1.35, p = 0.027), age (HR: 1.09, p < 0.001), and male sex (HR: 2.06, p = 0.037). None of SRIVR measured in the other myocardial walls were associated with cardiac outcome.

CONCLUSION

SRIVRinflat predicted adverse outcome in the general population, on top of conventional cardiovascular factors. However, its incremental value as a prognosticator remained limited.

Effect of Chronic Obstructive Pulmonary Disease (COPD) on Biventricular Mechanics in Patients Without Severe Airflow Obstruction

Background: Over the last 15 years, few echocardiographic studies have examined the biventricular mechanics by speckle tracking echocardiography (STE) in patients affected by chronic obstructive pulmonary disease (COPD) without advanced lung disease. We aimed to summarize the main findings of these studies and quantify the overall effect of COPD on biventricular mechanics in patients without severe airflow obstruction. Methods: Eligible studies assessing cardiac function by conventional transthoracic echocardiography (TTE), implemented with a STE analysis of left ventricular (LV)-global longitudinal strain (GLS) and/or right ventricular (RV)-GLS in COPD patients without severe airflow obstruction vs. healthy controls, were selected from the PubMed, Embase and Scopus databases. The primary endpoint was to quantify the effect of COPD on LV-GLS and RV-GLS in individuals without advanced lung disease. Continuous data [LV-GLS, RV-GLS, left ventricular ejection fraction (LVEF) and tricuspid annular plane systolic excursion (TAPSE)] were pooled as the standardized mean difference (SMD) comparing COPD cohorts with healthy controls. Results: Ten studies were included, totaling 682 COPD patients and 316 healthy controls. Overall, COPD showed a large effect on LV-GLS (SMD -1.296; 95%CI -2.010, -0.582, p < 0.001) and RV-GLS (SMD -1.474; 95% CI -2.142, -0.805, p < 0.001), a medium-to-large effect on TAPSE (SMD -0.783, 95% CI -0.949, -0.618, p < 0.001) and a small effect on LVEF (SMD -0.366, 95% CI -0.659, -0.074, p = 0.014). The I2 statistic value for the LV-GLS (91.1%), RV-GLS (88.2%) and LVEF (76.7%) studies suggested a high between-study heterogeneity, while that for the TAPSE (38.1%) studies was compatible with a low-to-moderate between-study heterogeneity. Egger's test yielded a p-value of 0.16, 0.48, 0.58 and 0.50 for LV-GLS, RV-GLS, LVEF and TAPSE studies, respectively, indicating an absence of publication bias. Meta-regression analyses excluded that the effect of COPD on biventricular mechanics might be influenced by potential confounders (all p > 0.05). Sensitivity analysis confirmed the robustness of the LV-GLS, RV-GLS and TAPSE studies' results. Conclusions: COPD appears to be independently associated with a mild attenuation of biventricular mechanics in patients with moderate airflow limitations, despite a preserved LVEF and TAPSE on conventional TTE. STE analysis may allow clinicians to identify COPD patients with subclinical myocardial dysfunction and an increased risk of heart failure and cardiovascular complications early.

Evolution and prognostic implications of cardiac damage in women after transcatheter aortic valve implantation

Recently, a cardiac damage staging system has been proposed in patients with severe AS to improve risk stratification, but there is still paucity of data in women. Accordingly, we aimed to characterize the change in cardiac damage after transcatheter aortic valve implantation (TAVI), and to assess the prognostic value of cardiac damage staging in women. A total of 334 women (mean age 81 ± 7 years) with severe AS undergoing TAVI were included and retrospectively analyzed. Echocardiography was performed before and 6 months after TAVI. Patients were classified according to the following stages of cardiac damage: 0 = no damage; 1 = left ventricular damage; 2 = left atrial or mitral valve damage; 3 = pulmonary vasculature or tricuspid valve damage; and 4 = right ventricular damage. The primary endpoint was all-cause mortality. Most patients presented with advanced heart failure symptoms (62% in NYHA III-IV). TAVI consistently improved cardiac damage of at least one stage in 43% of patients at 6-month follow-up. During a median follow-up of 48 months, 79 patients (24%) died. Each increment of both baseline (HR per 1-stage increment 1.537, P = 0.001) and follow-up (HR per 1-stage increment 1.714, P = 0.01) cardiac damage stage were independently associated with all-cause death. Moreover, the re-assessment of cardiac damage at 6-month follow-up provided incremental prognostic value over baseline assessment (Chi-square change = 6.885; P = 0.009). TAVI has a beneficial effect on cardiac function and remodeling in women. Cardiac damage assessed before and 6 months after TAVI showed to be consistently and independently associated with prognosis.

Impact of Intradialytic Weight Gain on Left Ventricular Function and Characteristics in Hemodialysis Patients

BACKGROUND

Pulmonary circulation is particularly overloaded in hemodialysis patients with high interdialytic weight gain (IDWG), as evidenced by deterioration in right ventricular function indices. This study aimed to evaluate the impact of the degree of fluid accumulation on left ventricular (LV) systolic and diastolic function and sizing characteristics.

METHODS

This is a post hoc analysis of a cross-over study in 41 hemodialysis patients. Study participants were stratified using the recommended threshold IDWG% into a higher (> 4.5%) and a lower (< 4.5%) IDWG% group. All participants underwent 4 echocardiographic assessments at the start and the end of the 2-day and the 3-day interdialytic interval.

RESULTS

Over the 2-day interval, stroke volume and cardiac output increments were more prominent in the higher IDWG% group (> 4.5% 22.97 ± 18.45 vs. < 4.5% 0.95 ± 29.1 mmHg, p = 0.006; > 4.5% 1.32 ± 1.39 vs. < 4.5% -0.36 ± 2.08 L/m2, p = 0.004, respectively). Over the 3-day interval, significant increments in stroke volume were observed for both groups. With regard to diastolic function, a significant increase in E wave, E/A, and E/E'm lateral ratios was observed over the 3-day interval, and significant between-group differences in interdialytic changes were detected for the E/A ratio (IDWG > 4.5% 0.35 ± 0.29 vs. < 4.5% 0.06 ± 0.44, p = 0.035) and the E wave (IDWG > 4.5% 0.31 ± 0.24 vs. < 4.5% 0.10 ± 0.19, p = 0.02). Left atrial dimensions and LV mass were enlarged to a similar extent in both study groups during both intervals.

CONCLUSIONS

Patients exceeding the recommended IDWG threshold experience more pronounced changes in indices of LV function and significant deterioration of preload-dependent indexes of LV diastolic function.

Reference ranges of left ventricular diastolic multimodal ultrasound parameters in stable preterm infants in the early and late neonatal intensive care admission period

BACKGROUND

Diastolic dysfunction often precedes systolic dysfunction and provides opportunity for management strategies. We aim to present reference ranges for diastolic function parameters in stable preterm infants at 2 timepoints.

METHODS

Ultrasound scans of clinically stable preterm infants < 30 weeks gestation with no antenatal or postnatal complications were analysed for left heart size, mitral blood flows, myocardial velocities and shortening during the early (3 to 21 days) and late (corrected gestation 34 to 37 weeks) neonatal period.

RESULTS

92 early scans and 64 late scans were included. Mitral blood flow and myocardial velocities increased with augmented atrial function leading to higher EA and e'a' ratios and with relatively high Ee' ratio.

CONCLUSION

We present reference values for many left ventricular multimodal diastolic ultrasound parameters in preterm infants with uncomplicated fetal and neonatal development to guide prospective studies that explore diastolic function and diastolic heart failure in preterm infants.

T2D-LVDD: neural network-based predictive models for left ventricular diastolic dysfunction in type 2 diabetes

Cardiovascular disease complications are the leading cause of morbidity and mortality in patients with Type 2 diabetes (T2DM). Left ventricular diastolic dysfunction (LVDD) is one of the earliest myocardial characteristics of diabetic cardiac dysfunction. Therefore, we aimed to develop an LVDD-risk predictive model to diagnose cardiac dysfunction before severe cardiovascular complications arise. We trained an artificial neural network model to predict LVDD risk with patients' clinical information. The model showed better performance than classical machine learning methods such as logistic regression, random forest and support vector machine. We further explored LVDD-risk/protective features with interpretability methods in neural network. Finally, we provided a freely accessible web server called LVDD-risk, where users can submit their clinical information to obtain their LVDD-risk probability and the most noteworthy risk indicators.

Differences in risk factors associated with the initiation and progression of mitral annular calcification in asymptomatic individuals

Mitral annular calcification (MAC) is hypothesized to be a representation of atherosclerosis and is associated with adverse outcomes. However, the pathophysiology and risk factors associated with MAC development are not fully understood. Using the KOrea Initiatives on Coronary Artery (KOICA) registry, 738 asymptomatic individuals who underwent health screening with echocardiography and serial cardiac computed tomography (CT) were included for analysis. MAC was identified on CT, and the severity was quantified using Agatston units (AU). Risk factors associated with prevalent MAC and the rate of MAC progression were identified using multivariable regression models. On initial CT, 52 (7.0%) participants showed prevalent MAC, and in this group the median MAC progression rate was 3.4 AU/year (interquartile range: 0.2-14.7) during a median interscan duration of 36.4 months. Factors associated with prevalent MAC were older age (p < 0.001), higher body-mass index (p = 0.04), diabetes (p < 0.01), higher systolic blood pressure (p < 0.01), and higher left atrial volume index (p = 0.02). Meanwhile, factors associated with faster MAC progression were initial MAC severity (p < 0.001), male sex (p < 0.01), and higher serum phosphate (p < 0.001). Traditional atherosclerotic risk factors have an important role in the initial process of MAC development. The association between left atrial volume index and prevalent MAC further suggests the implication of elevated left ventricular filling pressure in MAC initiation. Conversely, initial MAC severity and mineral metabolism were found to be major determinants in the later phase of MAC progression.

Obstructive sleep apnea is associated with cardiac structural and functional alterations in patients with advanced diabetic kidney disease

AIMS

Obstructive sleep apnea (OSA) is common in type 2 diabetes mellitus (T2DM), but its association with cardiac structure and function in advanced diabetic kidney disease (DKD) remains unclear.

METHODS

T2DM patients with estimated glomerular filtration rate (eGFR) <60 mL/min/1.73 m2 and albuminuria were assessed for OSA using the apnea-hypopnea index (AHI). Cardiac structure and function were assessed by transthoracic echocardiography following standard guidelines. 39 patients without OSA (AHI < 5) were compared to 34 patients with moderate-severe OSA (AHI ≥ 15).

RESULTS

Mean age was 71.4 ± 9.4 years (73 % male), and eGFR was 32.1 ± 12.3 mL/min/1.73 m2. DKD patients with moderate-severe OSA had a higher left atrial volume index (LAVI: 36.6 ± 13.9 vs. 28.1 ± 10.5 mL/m2, p < 0.01) left ventricular mass index (LVMI: 48.8 ± 11.7 vs. 41.8 ± 9.7 g/m2.7, p < 0.01) and right ventricular diameter (RVD: 34.1 ± 5.8 vs. 28.4 ± 4.4 mm, p < 0.001) than DKD patients without OSA. Left ventricular ejection fraction (LVEF) did not differ, but global longitudinal strain (GLS) was reduced (-15.1 ± 3.0 vs. -16.6 ± 2.8 %, p < 0.05). In multivariable linear regression analyses, moderate-severe OSA remained significantly associated with LAVI, LVMI, RVD, and GLS but not with LVEF.

CONCLUSIONS

Moderate-severe OSA is associated with cardiac hypertrophy and chamber dilatation, potentially contributing to cardiovascular risk in advanced DKD.

Clinical staging to guide management of metabolic disorders and their sequelae: a European Atherosclerosis Society consensus statement

Obesity rates have surged since 1990 worldwide. This rise is paralleled by increases in pathological processes affecting organs such as the heart, liver, and kidneys, here termed systemic metabolic disorders (SMDs). For clinical management of SMD, the European Atherosclerosis Society proposes a pathophysiology-based system comprising three stages: Stage 1, where metabolic abnormalities such as dysfunctional adiposity and dyslipidaemia occur without detectable organ damage; Stage 2, which involves early organ damage manifested as Type 2 diabetes, asymptomatic diastolic dysfunction, metabolic-associated steatohepatitis (MASH), and chronic kidney disease (CKD); and Stage 3, characterized by more advanced organ damage affecting multiple organs. Various forms of high-risk obesity, driven by maintained positive energy balance, are the most common cause of SMD, leading to ectopic lipid accumulation and insulin resistance. This progression affects various organs, promoting comorbidities such as hypertension and atherogenic dyslipidaemia. Genetic factors influence SMD susceptibility, and ethnic disparities in SMD are attributable to genetic and socioeconomic factors. Key SMD features include insulin resistance, inflammation, pre-diabetes, Type 2 diabetes, MASH, hypertension, CKD, atherogenic dyslipidaemia, and heart failure. Management strategies involve lifestyle changes, pharmacotherapy, and metabolic surgery in severe cases, with emerging treatments focusing on genetic approaches. The staging system provides a structured approach to understanding and addressing the multi-faceted nature of SMD, which is crucial for improving health outcomes. Categorization of SMD abnormalities by presence and progression is aimed to improve awareness of a multi-system trait and encourage a tailored and global approach to treatment, ultimately aiming to reduce the burden of obesity-related comorbidities.

Utilization of Transthoracic Echocardiography and Biochemical Markers in Detecting Cardiomyopathy in Fabry Disease

Background

Fabry disease (FD) is an X-linked lysosomal storage disorder caused by α-galactosidase A enzyme deficiency, resulting in multiorgan accumulation of glycosphingolipid. Cardiac accumulation leads to left ventricular hypertrophy, diastolic dysfunction, fibrosis, and sudden cardiac death. Advances in transthoracic echocardiograms (TTEs) have enabled the detection of subclinical atrial and ventricular cardiomyopathy. Until now, studies assessing changes on TTE in FD have been small and cross-sectional. To understand longitudinal changes, our aim was to quantify trends in TTE parameters, linked to relevant physiological and biochemical parameters.

Methods

A single-centre retrospective study was conducted of 75 FD patients who received longitudinal follow-up care (53% female, 57% on enzyme replacement therapy) between 2011 and 2023.

Results

Longitudinal follow-up care demonstrated increasingly impaired left ventricular global longitudinal strain (GLS), tissue Doppler imaging, and right ventricular systolic function. Atrial changes included increasingly impaired left atrial GLS, greater volumes, and reduced left atrial ejection fraction and fractional area change. A sex-specific increase occurred in indexed left ventricular mass in male patients. Biochemical changes included increases in high-sensitivity Troponin-T and N-terminal-pro-B-type natriuretic peptide levels. A sex-specific increase in the urine protein level and the albumin-creatinine ratio in male patients.

Conclusions

TTE and biochemical trends highlight the gradual and insidious nature of FD progression, and stress the importance of considering multiparametric endpoints, including GLS, atrial function, and biomarkers, when assessing outcome in FD.

Impact of Left Ventricular-Vascular Interaction on Long-Term Outcome After Heart Transplantation

BACKGROUND AND AIM

To compare pressure-volume (PV) derivative variables between HT patients and healthy controls and to assess their impact on long-term outcome.

METHODS

In this single-center retrospective study, HT patients surviving their first post-HT year with left ventricular ejection fraction (LVEF) ≥50%, absence of allograft vasculopathy, and rejection were enrolled. PV variable surrogates were measured by transthoracic echocardiography and compared with healthy controls. The endpoint was cardiovascular mortality.

RESULTS

From 1985 to 2015, 345 patients were enrolled. Arterial elastance (Ea) and left ventricular end-systolic elastance (Ees) were higher in HT recipients than in healthy controls (4.03 vs. 1.65, p < 0.0001 and 6.75 vs. 2.47, p < 0.0001, respectively), while ventricular arterial coupling (VAC) was similar between the two groups (0.66 vs. 0.59, p = 0.105). After a median of 11.3-year follow-up, 59 (17%) HT recipients died. VAC was not significantly associated with cardiac mortality (p = 0.074). Survival was lower in HT recipients with Ea > 4 mmHg/mL/m2 and Ees ≤ 6.75 mmHg/mL/m2, and both were independently associated with mortality risk after adjustment (Ea > 4 mmHg/mL/m2: HR 2.25 [95% CI 1.38-3.66], p = 0.013; Ees ≤ 6.75 mmHg/mL/m2: HR 3.70 [95% CI 1.95-7.06], p = 0.001).

CONCLUSIONS

In HT recipients surviving the first year after transplantation with normal LVEF, high Ea, and low Ees values were independently associated with poorer outcomes in long-term follow-up.

Predictors of Incident Heart Failure in Patients With Chronic Chagas Disease Cardiomyopathy

PURPOSE

Patients with chronic Chagas cardiomyopathy (CCC) have a high mortality due to heart failure (HF). The aim of this study was to investigate clinical and echocardiographic predictors of incident HF in patients with CCC.

METHODS

Single-center retrospective longitudinal observational study which included 176 adult patients (59.1% women; 53.9 ± 10 years old; mean left ventricular [LV] ejection fraction 62% ± 10%) at an early stage of CCC (electrocardiogram and/or wall motion changes but no HF). The primary outcome was incident HF. The association between studied parameters with incident HF was performed by competing-risk survival regression models using the Fine and Gray method.

RESULTS

After a mean follow-up of 8.8 ± 3.6 years, 42 patients progressed to HF (27.04 cases/1000 patient-years). A model 0 adjusted for clinical and 2D-Doppler echocardiographic parameters and for all-cause mortality revealed diabetes mellitus (HR 4.91, 95% CI 1.67-14.4, p = 0.004), LV ejection fraction (HR 0.96, 95% CI 0.93-0.99, p = 0.022), and E' velocity (HR 0.79, 95% CI 0.67-0.95, p = 0.01) as independently associated with incident HF. The addition of strain-derived parameters to model 0 revealed that LV global circumferential strain (HR 0.83, 95% CI 0.78-0.89, p < 0.001) and left atrial booster contraction strain (HR 1.14, 95% CI 1.02-1.28, p = 0.022) were associated with incident HF.

CONCLUSION

While most clinical parameters were not associated with incident HF in patients with CCC, echocardiographic parameters, including LV systolic and diastolic function and strain-derived parameters, were associated with incident HF in patients with CCC. This knowledge can be very useful for planning the care and follow-up of these patients.

The Role of Left Atrial Strain in Differentiating Embolic Stroke of Undetermined Source From Other Acute Ischemic Stroke Subtypes Related to Large-Vessel Occlusion

INTRODUCTION

To evaluate left atrial (LA) function in patients with embolic stroke of undetermined source (ESUS) and other subtypes of acute ischemic stroke (AIS) related to large-vessel occlusion (LVO).

METHODS

Consecutive patients with LVO-related AIS were prospectively enrolled from July 2019 to August 2022. To compare LA function with ESUS patients, a control group without prior stroke was sex- and age-matched with ESUS patients in a 1:1 ratio. LA strain was measured within 3 days after stroke. Multivariable logistic regression analysis was performed to assess associations between LA function and stroke subtypes.

RESULTS

This study included 126 patients (mean age 67.7 ± 12.3 year, 39.7% women). Of these, 28 patients met the diagnostic criteria for ESUS, while the remaining were classified as large artery atherosclerosis (n = 49) and non-valvular AF-related cardioembolic stroke (n = 49). Patients with ESUS had lower left atrial reservoir strain (LASr) and left atrial conduit strain (LAScd) compared to those with large artery atherosclerosis (27.8 ± 7.1% vs. 32.0 ± 5.3%, p = 0.004, and 14.3 ± 3.8% vs. 17.3 ± 4.6%, p = 0.005, respectively) and the control group (27.8 ± 7.1% vs. 37.6 ± 7.2%, p < 0.001 and 14.3 ± 3.8% vs. 21.5 ± 7.9%, p < 0.001, respectively). A 5% reduction in LASr and LAScd was associated with a 1.92- and 2.45-fold increase, respectively, in the likelihood of having ESUS compared to large artery atherosclerosis. Lower LASr and LAScd in ESUS patients were prone to be associated with a higher likelihood of cardiovascular events during follow-up.

CONCLUSIONS

LA strain is associated with ESUS in stroke patients with LVO. Further studies are needed to explore its utility in identifying specific stroke etiologies.

Clinical value of a comprehensive clinical- and echocardiography-based risk score on predicting cardiovascular outcomes in ischemic heart failure patients with reduced ejection fraction

AIMS

The present study aimed to develop a comprehensive clinical- and echocardiography-based risk score for predicting cardiovascular (CV) adverse outcomes in patients with ischemic heart failure (IHF) and reduced left ventricular ejection fraction (LVEF).

METHODS

This retrospective cohort study included 1341 hospitalized patients with IHF and LVEF < 50% at our hospital from 2009 to 2017. Cox regression models and nomogram were utilized to develop a comprehensive prediction model (C&E risk score) for CV mortality and CV-related events (hospitalization or death).

RESULTS

Over a median 26-month follow-up, CV mortality and CV events rates were 17.4% and 40.9%, respectively. The C&E risk score, incorporating both clinical and echocardiographic factors, demonstrated superior predictive performance for CV outcomes compared to models using only clinical or echocardiographic factors. Internal validation confirmed the stable predictive ability of the C&E risk score, with an AUC of 0.740 (95% CI 0.709-0.775, P < 0.001) for CV mortality and an AUC of 0.678 (95% CI 0.642-0.696, P < 0.001) for CV events. Patients were categorized into low-, intermediate-, and high-risk based on the C&E risk score, with progressively increasing CV mortality (5.3% vs. 14.6% vs. 31.9%, P < 0.001) and CV events (28.8% vs. 38.2% vs. 55.0%, P < 0.001). External validation also confirmed the risk score's prognostic efficacy within additional IHF patient datasets.

CONCLUSION

This study establishes and validates the novel C&E risk score as a reliable tool for predicting CV outcomes in IHF patients with reduced LVEF. The risk score holds potential for enhancing risk stratification and guiding clinical decision-making for high-risk patients.

Impact of empagliflozin on cardiac structure and function assessed by echocardiography after myocardial infarction: a post-hoc sub-analysis of the emmy trial

BACKGROUND

Empagliflozin administered after acute myocardial infarction proofed to improve cardiometabolic parameters and biomarkers, but the impact on cardiac function is still largely unknown. The aim of this post-hoc echocardiographic sub-analysis of the EMMY trial was to provide in-depth echocardiographic analysis on the effects of empagliflozin versus placebo on standard and novel echocardiographic structural and functional parameters after acute myocardial infarction.

METHODS

In this post-hoc analysis of the EMMY trial a subset of 313 patients (157 empagliflozin vs. 156 placebo) was enrolled for post-processing analysis of echocardiographic structural and functional parameters. On top of two-dimensional and Doppler parameters, myocardial deformation analyses were performed to assess ventricular and atrial strain values.

RESULTS

Left ventricular volumes showed significant differences in favor of empagliflozin over the course of the trial (change in left ventricular end-diastolic volume median [interquartile range] 8 [-3;19]% versus 13 [0;29]%, p = 0.048; left ventricular end-systolic volume -3 [-15;12]% versus 4 [-12;18]%, p = 0.044). This effect persisted after adjusting for baseline values, age, and sex. Left ventricular systolic and diastolic function overall improved over the course of the trial and parameters for diastolic function showed a distinct trend between groups but did not meet statistical significance in this cohort.

CONCLUSION

In this post-hoc analysis among patients with acute myocardial infarction, treatment with empagliflozin resulted in a significant beneficial effect on left ventricular end-diastolic and end-systolic volume, without significantly improving left ventricular or right ventricular functional parameters compared to placebo after 26 weeks.

CLINICALTRIALS

GOV REGISTRATION

NCT03087773.

Subclinical left ventricular dysfunction assessed by global longitudinal strain correlates with mild cognitive impairment in hypertensive patients

Prevention of dementia represents a public health priority. Hypertension is a risk factor for mild cognitive impairment (MCI), a precursor to progressive dementia. A great effort is underway to develop accurate and sensitive tools to detect the MCI condition in hypertensive patients. To investigate the potential association of subclinical left ventricular dysfunction expressed by the global longitudinal strain (GLS) with the MCI, defined by the Italian version of the quick mild cognitive impairment (Qmci-I). This multi-centric study included 180 consecutive hypertensive patients without medical diseases and/or drugs with known significant effects on cognition but with a not negligible comorbidity burden to avoid a possible "hyper-normality bias". The study cohort was classified into two main groups concerning the median value of the GLS. A weighted logistic regression model was employed after an inverse probability of treatment weighting (IPTW) analysis to characterize a potential association between GLS and MCI. Almost 41,1% of the whole study population was female. The mean age was 65,6 ± 7,2. 39 patients (21,7%) showed MCI. After IPTW, the GLS was significantly associated with the study endpoint (OR, 1,22; 95% CI: 1,07-1,39, P = 0.003). Our results highlight that the GLS is a potential predictor of MCI and, therefore, a valuable tool for establishing preventive strategies to arrest the progression toward a cognitive decline in hypertensive patients.

The reversibility of cardiac damage after transcatheter aortic valve implantation and short-term outcomes in a real-world setting

AIMS

This study aims to assess the changes in cardiac damage stage in a real-world cohort of patients undergoing transcatheter aortic valve implantation (TAVI), and to investigate the prognostic value of cardiac damage stage evolution.

METHODS AND RESULTS

Patients with severe aortic stenosis (AS) undergoing TAVI were retrospectively analysed. A five-stage system based on the presence and extent of cardiac damage assessed by echocardiography was applied before and 6 months after TAVI. Multivariable Cox regression analyses were used to examine independent prognostic value of the changes in cardiac damage after TAVI. A total of 734 patients with severe AS (mean age, 79.8 ± 7.4 years; 55% male) were included. Before TAVI, 32 (4%) patients did not show any sign of extra-valvular cardiac damage (Stage 0), 85 (12%) had left ventricular damage (Stage 1), 220 (30%) left atrial and/or mitral valve damage (Stage 2), 227 (31%) pulmonary vasculature and/or tricuspid valve damage (Stage 3), and 170 (23%) right ventricular damage (Stage 4). Six months after TAVI, 39% of the patients improved at least one stage in cardiac damage. Staging of cardiac damage at 6 months after TAVI [hazard ratio (HR) per one-stage increase, 1.391; P = 0.035] as well as worsening in the stage of cardiac damage (HR, 3.729; P = 0.005) were independently associated with 2-year all-cause mortality.

CONCLUSION

More than one-third of patients with severe AS showed an improvement in cardiac damage 6 months after TAVI. Staging cardiac damage at baseline and follow-up may improve risk stratification in patients undergoing TAVI.

A scoring system for diagnosing heart failure with preserved ejection fraction based on exercise echocardiography

AIMS

Exercise stress echocardiography (ESE) is often used to identify heart failure with preserved ejection fraction (HFpEF) in patients presenting dyspnoea. However, diagnostic criteria have not been standardized. Here, we sought to develop ESE-based criteria to diagnose HFpEF in dyspnoeic patients.

METHODS AND RESULTS

A total of 81 consecutive patients with dyspnoea who underwent exercise right heart catheterization and ESE were evaluated. Diagnosis of HFpEF was ascertained by directly-measured haemodynamics (61 HFpEF and 20 controls). Logistic regression analysis was applied to develop an ESE-based scoring system to diagnose HFpEF. Multivariable logistic regression analysis identified resting left atrial reservoir strain < 20%, exercise septal E/e' ratio > 13, and increases in ultrasound B-lines as independent predictors of HFpEF. A weighted score was created with these variables (the ESE score) ranging from 0 to 5. The ESE score accurately discriminated HFpEF from controls [area under the curve (AUC) 0.90, P < 0.0001], with a superior diagnostic ability to the ASE/ESCVI criteria (AUC comparison P < 0.0001). The ESE score classified the HFpEF probability into three categories (probabilities: low risk 28%, intermediate risk 59-83%, and high risk 95-99%). In a cohort of 620 dyspnoeic patients, the predictive ability of the derived score was assessed. A higher ESE score was associated with an increased risk of all-cause mortality or worsening HF events even after adjusting for confounders (hazard ratio; 1.17 per 1-point increase, 95% confidence intervals; 1.00-1.37, P = 0.04).

CONCLUSION

The ESE score, which is based on three echocardiographic variables, may be an effective tool for diagnosing HFpEF on exercise echocardiography.

Cardiac magnetic resonance assessment of cardiac function across chronic kidney disease stages

BACKGROUND

Cardiovascular disease prevalence remains high among chronic kidney disease (CKD) patients. Mechanisms and treatments to improve prognosis remain of paramount importance, and imaging biomarkers of left ventricular myocardial structure and function have better defined the phenotype of renal cardiomyopathy. The left atrial function and right heart remain are less well reported in CKD. This study used cardiac magnetic resonance imaging (CMR) to assess the interplay of left atrial and right ventricular function.

METHODS

In a cross-sectional study, we examined 58 CKD patients (Group I: stages 2-3, n = 25; Group II: stages 4-5, n = 33). Additionally, 26 age-matched healthy controls were included. Comprehensive CMR protocols (1.5T) were employed, encompassing cine imaging, native T1 and T2 mapping, and tissue tracking strain analysis. Left ventricular (LV), right ventricular (RV) and left atrial (LA) structure, function and strain parameters were assessed.

RESULTS

Compared with healthy controls, both Groups I and II exhibited impaired RV and LA function. right ventricular end-diastolic volume index and right ventricular end-systolic volume index showed significant increases in both Groups I and II (P < .001). All LV, RV and LA strain parameters were reduced in the patient groups (all P < .001). In the univariate binary logistic regression, several parameters, including age, blood pressure, RV volumes and LV/RV strain, were found to have a statistically significant association with CKD. In a multivariable model adjusted for other confounders, RV GLS and left atrial strain remained as independent significant predictors.

CONCLUSIONS

RV size, LA strain and volume assessed by CMR serve as markers of RV and LA cardiac dysfunction in CKD patients with preserved LVEF. Greater attention should be given to RV and LA dysfunction for early identification of cardiac dysfunction in CKD patients.

Normal Values of Echocardiographic Left Atrioventricular Coupling Index and Left Atrial Stiffness Index Reflecting Left Ventricular Diastolic Function: A Multicenter Study

BACKGROUND

The left atrioventricular coupling index (LACI) and left atrial stiffness index (LASI) have recently demonstrated significant correlations with left ventricular (LV) diastolic function. However, the absence of reference values limits their widespread use. This study aimed to establish normal reference ranges for LACI and LASI.

METHODS

A total of 1,648 healthy participants from 55 centers were enrolled. The LACI was defined as the ratio of left atrial (LA) minimum volume to LV end-diastolic volume. The LASI was calculated as the ratio of the average E/e' ratio to LA reservoir strain.

RESULTS

Both LACI and LASI increased with age in both sexes. The LACI was higher in women than in men (P < .001), whereas no significant sex difference was observed for LASI (P = .868). Age, sex, LV global longitudinal strain (GLS), and LA reservoir strain independently predicted LACI. Age, body mass index, LV GLS, and LA volume index were independently associated with LASI. Elevated LACI and LASI were observed in participants with high-normal blood pressure, overweight status, and indeterminate LV diastolic function.

CONCLUSIONS

Sex- and age-stratified reference values for LACI and LASI were established. Left ventricular GLS, LA reservoir strain, and LA volume index should be considered when interpreting these parameters. Hypertension, obesity, and LV diastolic dysfunction may significantly affect LACI and LASI, suggesting their potential utility in identifying early cardiac dysfunction.

Diagnostic value of lung ultrasound B-lines for evaluating left ventricular filling pressure

BACKGROUND

The assessment of left ventricular (LV) diastolic function based on the American Society of Echocardiography and the European Association of Cardiovascular Imaging (ASE/EACVI) guidelines requires measurement of several echocardiographic indices. However, these assessments often yield inconclusive results owing to the absence of measurable parameters. Multiple B-lines on lung ultrasound have been proposed as a method for evaluating pulmonary congestion. We aimed to evaluate the association between B-lines and LV diastolic function and to examine whether B-lines show potential as an alternative to conventional indices for assessing LV diastolic function.

METHODS

This prospective study included 172 patients with pre-heart failure (HF) or HF. We investigated (i) the relationship between B-lines and LV diastolic function using echocardiography, (ii) the diagnostic accuracy of B-lines compared to echocardiography indices for estimating LV filling pressures and (iii) the relationship between B-lines and risk of hospitalisation for HF.

RESULTS

Among patients for whom the ASE/EACVI guideline algorithm for LV diastolic dysfunction was available (n = 89), the number of B-lines typically increased with the severity of diastolic dysfunction grade. In patients who underwent left heart catheterisation (n = 20), the LV filling pressure was significantly correlated with B-lines (r = 0.690, P < 0.001). The diagnostic accuracy of B-lines for detecting high LV filling pressure was comparable to that of tricuspid regurgitation peak gradient (TRPG). When TRPG was replaced with B-lines to diagnose grade II or III diastolic dysfunction using the ASE/ESCVI algorithm, sensitivity remained comparable (0.80); however, specificity improved (0.80 vs. 0.50). In patients who underwent lung ultrasound while they were hemodynamically stable and were followed up for prognosis (median, 730 days; n = 75), 14 hospitalisations for HF were observed. Kaplan-Meier analysis revealed that the high B-line group had a significantly higher incidence of hospitalisation events for HF (P = 0.036, log-rank test).

CONCLUSION

B-lines have shown potential as an alternative to conventional indices for assessing LV diastolic dysfunction.

Prognostic implications of multiple chamber longitudinal strains and myocardial work in restrictive cardiomyopathy

The prognosis for restrictive cardiomyopathy (RCM) is typically poor, which primarily influenced by the restrictive physiology. This study aimed to evaluate the prognostic significance of longitudinal strains and myocardial work (MW) indices in RCM patients and to create and validate a multivariable model for predicting major adverse cardiac events (MACEs). We enrolled 191 patients with RCM, divided into a training cohort of 128 and a validation cohort of 63, along with 132 healthy controls. Echocardiography was used to assess right ventricular free wall strain (RV-FWS), left ventricular global longitudinal strain (LV-GLS), left atrial peak strain (LAPS), right atrial peak strain (RAPS), and MW indices. Univariate and multivariate stepwise Cox regressions were applied to identify independent prognostic factors and develop a nomogram. With a median follow-up of 977 days, 111 patients experienced MACEs and 76 died. In patients with preserved left ventricular ejection fraction (LVEF), LV-GLS and MW indices were impaired. Longitudinal strains and MW indices were significantly associated with prognosis. We constructed a predictive nomogram including LAPS, RV-FWS, global myocardial work efficiency (GWE), and established clinical predictors, which demonstrated excellent discriminative and calibration properties. Thorough evaluation of longitudinal strains and MW indices is essential, particularly focusing on LAPS, RV-FWS, and GWE.

Characteristics of pulmonary hypertension in adults with left ventricular diastolic dysfunction

BACKGROUND AND OBJECTIVES

Left ventricular diastolic dysfunction (LVDD) is commonly associated with pulmonary hypertension (PHT); however, the factors associated with the presence and severity of PHT in patients with LVDD have not been well characterised.

METHODS

We analysed the profiles and echo characteristics of 16 058 adults with LVDD and preserved left ventricular ejection fraction (LVEF, >50%) from the National Echocardiography Database of Australia. Peak tricuspid regurgitation velocity (TRV) was used to determine the presence of PHT. Univariate and multivariate analyses were performed to evaluate the parameters associated with the presence/increasing severity of PHT.

RESULTS

Mean age was 73±12 years and 9216 (57.4%) were women. 2503 (15.6%) subjects had atrial fibrillation (AF) and 13 555 (84.4%) were in sinus rhythm. Overall, 9976 (62.1%) had PHT (TRV >2.9 m/s). There was a progressive increase in indexed left atrial volume with rising TRV levels. AF and right ventricular (RV) dilation were strongly associated with the presence of PHT (adjusted OR (aOR) 1.27 (95% CI 1.12 to 1.43) and aOR 4.99 (95% CI 4.44 to 5.62), respectively). Increased age, LVEF and body mass index were also independently associated with PHT (p<0.001). On multivariate analysis, older age, female sex, AF, lower E/e' and LVEF were independently associated with the severity of PHT (p<0.001). The presence of AF increased the TRV by an average of 0.32 m/s, RV dilation by 1.82 m/s, female sex by 0.32 m/s and age (per decade) by 0.3 m/s.

CONCLUSION

In this large study, PHT was common in LVDD and was strongly associated with the presence of enlarged left atrium, AF and older age, in particular.

TRIAL REGISTRATION NUMBER

ACTRN12617001387314.

Sex Differences in Embolic Stroke of Undetermined Source: Echocardiographic Features and Clinical Outcomes

BACKGROUND

Sex differences in stroke are well-documented, but in embolic stroke of undetermined source (ESUS) remains underexplored. This study aims to investigate sex-related differences in clinical and cardiac features and stroke outcomes in ESUS.

METHODS

Retrospective observational single-center study including consecutive ESUS patients. Multivariate regression analyses evaluated the association between sex, echocardiographic features, and 90-day outcomes. Cox regression assessed the independent effect of sex on ischemic stroke recurrence, all-cause death, and atrial fibrillation detection after stroke (AFDAS).

RESULTS

Among 556 patients, 248 (44.6%) were women, who were older and had more severe strokes. Women exhibited larger left atria (LA) as evidenced by a higher LA volume index (adjusted β-coefficient = 2.59, 95% CI 0.53-4.65, p = 0.014) and more valve abnormalities, such as mitral annulus calcification (aOR 2.72; 95% CI 1.43-5.20, p = 0.002). Men showed more markers of left ventricular (LV) disease, including reduced ejection fraction < 50% (aOR 0.44; 95% CI 0.20-0.93, p = 0.033) and LV wall motion abnormalities (aOR 0.37; 95% CI 0.19-0.74, p = 0.005). In multivariate analyses, the female sex was independently associated with reduced all-cause death (aHR 0.59; 95% CI 0.38-0.91, p = 0.019) and showed a trend toward higher AFDAS risk (aHR 1.57; 95% CI 0.99-2.49, p = 0.053). No association was found with 90-day outcomes or stroke recurrence.

CONCLUSION

ESUS patients exhibit significant sex-based differences in echocardiographic features, with women showing larger LA and more valve abnormalities, while men present greater LV dysfunction. Female sex is independently associated with a lower risk of long-term mortality and a potentially higher risk of AFDAS. These findings underscore the need for individualized, sex-specific ESUS management strategies.

Right ventricular-pulmonary artery coupling assessed by two-dimensional strain predicts in-hospital complications in Takotsubo syndrome

BACKGROUND

Takotsubo syndrome (TTS) is an acute condition characterized by a reversible left ventricular (LV) systolic dysfunction leading to serious in-hospital complications (IHC). The aim of our study is to investigate the prognostic impact of right ventricular-to-pulmonary artery (RV-PA) coupling in patients with TTS.

METHODS

Consecutive TTS patients were prospectively enrolled. In all patients, standard and speckle tracking transthoracic echocardiography was performed within 48 h from hospital admission. RV function was evaluated by RV global longitudinal strain (RV-GLS) and RV free wall strain (RV-FWS) and RV-PA coupling was measured as the ratio of either tricuspid annular plane systolic excursion (TAPSE), RV-GLS or RV-FWS to pulmonary artery systolic pressure (PASP). Data about IHC (acute heart failure, life-threatening arrhythmias and death) were collected.

RESULTS

A total of 80 patients were analyzed (71 ± 11 years, female 77.5 %) and IHC occurred in 33 (41 %). Patients who experienced IHC had lower LV ejection fraction (LVEF), lower left atrial (LA) reservoir strain, TAPSE/PASP, RV-FWS/PASP and RV-GLS/PASP and higher left atrial volume indexed (LAVi) values. At multivariate analysis, only LVEF (OR 0.913, 95 % CI [0.858-0.971], p = 0.004) was an independent predictor of IHC. Receiver operating characteristics (ROC) curve analysis showed an additional prognostic value of a combined model including RV-GLS/PASP and LVEF compared to LVEF alone in the prediction of IHC (AUC of 0.756 vs 0.736, differences between AUCs: 0.02 [p = 0.73]).

CONCLUSION

RV-PA coupling assessed by RV-GLS/PASP may help in identifying TTS patients at higher risk of cardiovascular complications with an additional prognostic value to LVEF alone.

Use of Advanced Echocardiographic Modalities to Discriminate Preclinical Hypertrophic Cardiomyopathy Mutation Carriers From Non-Carriers

BACKGROUND

It remains challenging to determine which hypertrophic cardiomyopathy (HCM) family members will subsequently develop HCM. Standard 2-dimensional and conventional Doppler echocardiography have been unable to reliably distinguish HCM genotype-positive and phenotype-negative (G+P-) from genotype-negative and phenotype-negative (G-P-) family members. We aimed to determine if advanced echocardiographic modalities can discriminate HCM G+P- from G-P- individuals.

METHODS

Comprehensive echocardiography including speckle tracking evaluation of myocardial deformation and color M-mode were performed in 199 participants aged ≥16 years who had undergone genetic testing from families with a known HCM pathogenic variant: 58 G+P-, 39 G-P-, and 102 overt patients with HCM (genotype-positive and phenotype-positive). The primary analysis compared these measures in all G+P- and G-P- individuals. A secondary analysis was undertaken in younger subjects (age ≤40 years).

RESULTS

Comparing G+P- and G-P- individuals, there were no significant differences in left ventricular ejection fraction, cavity size, wall thickness and outflow tract gradient, and tissue Doppler-derived myocardial velocities; however, septal/posterior wall thickness ratio was higher (1.06±0.09 versus 1.02±0.04, P=0.007). G+P- individuals had significantly lower color M-mode flow propagation velocity (color M-mode velocity propagation, 42.6 cm/s [interquartile range, 34.5-48.5 cm/s] versus 51.0 cm/s [interquartile range, 45.2-61.0 cm/s]; P<0.001) and higher global longitudinal strain (P=0.021), circumferential strain (P=0.003), and peak apical rotation (P=0.005). Multivariable logistic regression identified 2 independent predictors (color M-mode velocity propagation and peak apical rotation). A derived regression equation allowed reasonable discrimination of G+P- individuals with a sensitivity of 82.6% and specificity of 72.2% (P<0.0001) at the optimal cutoff. Similar findings were demonstrated when the analysis was restricted to younger subjects, although in addition to color M-mode velocity propagation and apical rotation, left ventricular ejection fraction was also independently predictive.

CONCLUSIONS

In HCM family members, color M-mode velocity propagation and apical rotation provide good sensitivity and specificity for identifying mutation carriers and may represent early disease markers before the onset of hypertrophy. Longitudinal studies involving larger cohorts are required to validate these findings.

Association between interleukin-6, suPAR, and hsCRP with subclinical left ventricular dysfunction in type 1 diabetes: The Thousand & 1 study

AIMS

To investigate the association between chronic inflammation and subclinical left ventricular dysfunction in type 1 diabetes (T1D).

METHODS

In a cross-sectional study of individuals with T1D without known heart disease, interleukin-6 (IL-6), soluble-urokinase-plasminogen-activator-receptor (suPAR), and high-sensitivity C-reactive-protein (hsCRP) were examined for associations with echocardiographic E/e' (primary outcome) and global longitudinal strain (GLS) (secondary outcome). We adjusted for several clinical variables in linear regression analysis, including N-terminal pro-B-type natriuretic peptide (NT-proBNP). The biomarkers were categorized as elevated/non-elevated based on their upper quartiles.

RESULTS

Of 962 individuals (52 % male, mean age 49 ± 14 years), mean E/e' was 7 ± 3 and GLS 18 ± 3. In fully adjusted models, all biomarkers were each associated with increased E/e': beta coefficients for IL-6 0.2 (95 % confidence intervals: 0.1-0.3, P = 0.001), suPAR 0.5 (0.1-0.7, P = 0.011), and hsCRP 0.1 (0.0-0.2, P = 0.023). Combining biomarkers showed stronger associations: elevated IL-6 and suPAR 1.3 (0.7-2.0, P < 0.001), elevated all three 1.9 (1.1-2.7, P < 0.001). Results were similar for decreased GLS with IL-6-0.4 (-0.7 to 0.0, P = 0.039), IL-6 and hsCRP -1.0 (-1.7 to -0.4, P = 0.007), all three -1.1 (-2.0 to -0.3, P = 0.009).

CONCLUSIONS

Inflammatory biomarkers are independently associated with subclinical left ventricular dysfunction. Chronic inflammation may contribute to the development of myocardial dysfunction in T1D.

Utility of an Echocardiographic Machine Learning Model to Predict Outcomes in Intensive Cardiac Care Unit Patients

INTRODUCTION

The risk stratification at admission to the intensive cardiac care unit (ICCU) is crucial and remains challenging.

OBJECTIVES

We aimed to investigate the accuracy of a machine learning (ML)-model based on initial transthoracic echocardiography (TTE) to predict in-hospital major adverse events (MAEs) in a broad spectrum of patients admitted to ICCU.

METHODS

All consecutive patients hospitalized in ICCUs with a complete TTE performed within the first 24 hours of admission were included in this prospective multicenter study (39 centers). Sixteen TTE parameters were evaluated. The ML model involved automated feature selection by random survival forest and model building with an extreme gradient boosting (XGBoost) algorithm. The primary outcome was in-hospital MAEs defined as all-cause death, resuscitated cardiac arrest, or cardiogenic shock.

RESULTS

Of 1,499 consecutive patients (63 ± 15 years, 70% male), MAEs occurred in 67 patients (4.5%). The 5 TTE parameters selected in the model were left ventricular outflow tract velocity-time integral, E/e' ratio, systolic pulmonary artery pressure, tricuspid annular plane systolic excursion, and left ventricular ejection fraction. Using the XGBoost, the ML model exhibited a higher area under the receiver operating curve compared with any existing scores (ML model, 0.83 vs logistic regression, 0.76, ACUTE-HF score:,0.66; thrombolysis in myocardial infarction score, 0.60; Global Registry of Acute Coronary Events score, 0.58, all P < .001). The ML model had an incremental prognostic value for predicting MAE over a traditional model including clinical and biological data (C index 0.80 vs 0.73, P = .012; chi-square 59.7 vs 32.4; P < .001).

CONCLUSION

The ML model based on initial TTE exhibited a higher prognostic value to predict in-hospital MAEs compared with existing scores or clinical and biological data in the ICCU.

Cardiac remodelling in the era of the recommended four pillars heart failure medical therapy

Cardiac remodelling is a key determinant of worse cardiovascular outcome in patients with heart failure (HF) and reduced ejection fraction (HFrEF). It affects both the left ventricle (LV) structure and function as well as the left atrium (LA) and the right ventricle (RV). Guideline recommended medical therapy for HF, including angiotensin-converting enzyme inhibitors/angiotensin receptors II blockers/angiotensin receptor blocker-neprilysin inhibitors (ACE-I/ARB/ARNI), beta-blockers, mineralocorticoid receptor antagonists (MRA) and sodium-glucose transport protein 2 inhibitors (SGLT2i), have shown to improve morbidity and mortality in patients with HFrEF. By targeting multiple pathophysiological pathways, foundational HF therapies are supposed to drive their beneficial clinical effects by a direct myocardial effect. Simultaneous initiation of guideline directed medical therapy (GDMT) through a synergistic effect promotes a 'reverse remodelling', leading to a full or partial recovered structure and function by enhancing systemic neurohumoral regulation and energy metabolism, reducing cardiomyocyte apoptosis, lowering oxidative stress and inflammation and adverse extracellular matrix deposition. The aim of this review is to describe how these classes of drugs can drive reverse remodelling in the LV, LA and RV and improve prognosis in patients with HFrEF.

Cardiac Remodeling and Arrhythmic Burden in Pre-Transplant Cirrhotic Patients: Pathophysiological Mechanisms and Management Strategies

Background: Chronic liver disease (CLD) and cirrhosis contribute to approximately 2 million deaths annually, with primary causes including alcohol-related liver disease (ALD), metabolic dysfunction-associated steatotic liver disease (MASLD), and chronic hepatitis B and C infections. Among these, MASLD has emerged as a significant global health concern, closely linked to metabolic disorders and a leading cause of liver failure and transplantation. Objective: This review aims to highlight the interplay between cirrhosis and cardiac dysfunction, emphasizing the pathophysiology, diagnostic criteria, and management of cirrhotic cardiomyopathy (CCM). Methods: A comprehensive literature review was conducted to evaluate the hemodynamic and structural cardiac alterations in cirrhosis. Results: Cirrhosis leads to portal hypertension and systemic inflammation, contributing to CCM, which manifests as subclinical cardiac dysfunction, impaired contractility, and electrophysiological abnormalities. Structural changes, such as increased left ventricular mass, myocardial fibrosis, and ion channel dysfunction, further impair cardiac function. Vasodilation in the splanchnic circulation reduces peripheral resistance, triggering compensatory tachycardia, while the activation of the renin-angiotensin-aldosterone system (RAAS) promotes fluid retention and increases cardiac preload. Chronic inflammation and endotoxemia exacerbate myocardial dysfunction. The 2005 World Congress of Gastroenterology (WCG) and the 2019 Cirrhotic Cardiomyopathy Consortium (CCC) criteria provide updated diagnostic frameworks that incorporate global longitudinal strain (GLS) and tissue Doppler imaging (TDI). Prolonged QT intervals and arrhythmias are frequently observed. Managing heart failure in cirrhotic patients remains complex due to intolerance to afterload-reducing agents, and beta-blockers require careful use due to potential systemic hypotension. The interaction between CCM and major interventions, such as transjugular intrahepatic portosystemic shunt (TIPS) and orthotopic liver transplantation (OLT), highlights the critical need for thorough preoperative cardiac evaluation and vigilant postoperative monitoring. Conclusions: CCM is a frequently underdiagnosed yet significant complication of cirrhosis, impacting prognosis, particularly post-liver transplantation. Early identification using echocardiography and thorough evaluations of arrhythmia risk in cirrhotic patients are critical for optimizing management strategies. Future research should focus on targeted therapeutic approaches to mitigate the cardiac burden in cirrhotic patients and improve clinical outcomes.

Integrating Left Atrial Reservoir Strain Into the First-Line Assessment of Diastolic Function: Prognostic Implications in a Community-Based Cohort With Normal Left Ventricular Systolic Function

BACKGROUND

Left atrial (LA) reservoir strain (LASr) has emerged as a sensitive marker of LA function and elevated filling pressures, even though its role in detecting diastolic dysfunction (DD) and the subsequent risk stratification has remained relatively underexplored. Accordingly, we aimed to investigate the prognostic implications of replacing LA volume index (LAVi) with LASr in the 2016 American Society of Echocardiography/European Association of Cardiovascular Imaging (ASE/EACVI) algorithm for diagnosing DD, compared to the 2024 British Society of Echocardiography (BSE) algorithm, in individuals with normal left ventricular (LV) systolic function.

METHODS

We retrospectively identified 1,180 volunteers from a population-based screening program with normal LV systolic function and no evidence of myocardial disease. Echocardiographic measurements comprised recommended parameters of diastolic function and LASr by speckle-tracking. Diastolic function was assessed using the BSE algorithm and the modified ASE/EACVI algorithm, in which LAVi >34 mL/m2 was replaced with LASr <23%. The primary endpoint was the composite of all-cause mortality and heart failure hospitalization.

RESULTS

During a median follow-up of 11 years, 133 (11%) individuals met the primary endpoint. Using the BSE algorithm, there was no difference in the risk of meeting the primary endpoint between individuals with normal diastolic function and those with impaired diastolic function with normal filling pressures. In univariable analysis, individuals having impaired diastolic function with elevated filling pressures exhibited a significantly higher risk than those in the other 2 groups (unadjusted hazard ratios = 4.408 [95% CI, 2.376-8.179], P < .001; and 5.137 [95% CI, 1.138-23.181], P = .033, respectively). However, these differences were no longer significant after adjusting for relevant covariates. In contrast, the modified ASE/EACVI algorithm identified 3 groups with distinct risk profiles, and even in multivariable analysis, individuals with DD had a higher risk of meeting the primary endpoint than those with normal diastolic function (adjusted hazard ratio = 3.199 [95% CI, 1.534-6.671], P = .002).

CONCLUSION

In a community-based cohort with normal LV function, integrating LASr into the first-line echocardiographic assessment of diastolic function improved both classification and subsequent risk stratification.

Sex Hormone-Binding Globulin and Cardiac Function in Men with Heart Failure: Possible Role of Diabetes

Background: The association of sex hormone-binding globulin (SHBG) with heart failure (HF) remains a topic of ongoing debate, particularly in the light of type 2 diabetes mellitus (T2DM). We aimed to assess the association of SHBG with clinical and echocardiographic parameters of HF in men according to the presence of T2DM. Methods: Data on baseline characteristics, cardiovascular risk factors and medications, laboratory findings including serum SHBG and total testosterone concentrations, and echocardiographic parameters were prospectively collected for 215 male patients consecutively hospitalized for an acute episode of HF. Results: Patients with T2DM were older (p = 0.013), had a greater body mass index (p = 0.009) and NYHA class (p = 0.001), and were more likely to have hypertension (p < 0.001) or hyperlipidemia (p = 0.032). A moderate correlation among SHBG and total testosterone with the left ventricular ejection fraction (LVEF) was observed only in T2DM patients (r = 0.456) but not among non-T2DM patients (r = 0.194). A multivariate analysis revealed the independent association of increased SHBG levels with lower LVEF values among T2DM patients (ß = -0.542, p < 0.0001), whereas in the same group higher total testosterone was an independent predictor of higher LVEF (ß = 0.531, p < 0.0001) and lower LVDD (ß = -0.442, p = 0.0002) levels. Conclusions: In men with HF and T2DM, in contrast to testosterone, SHBG may have an independent adverse impact on the LVEF, which may account for 12.5% of the variance in LVEF levels. The possible subcellular mechanisms of SHBG in men with diabetic myocardial disorder should be additionally explored.

Diagnosing Heart Failure with Preserved Ejection Fraction in Obese Patients

Obesity is a current pandemic that sets all affected individuals at risk of heart failure (HF), and the majority of them will develop the clinical syndrome of HF with preserved ejection fraction (HFpEF). The diagnosis of HFpEF is challenging as it is based on the detection of subtle functional and structural remodeling of the heart that leads to diastolic dysfunction with increased left ventricular (LV) filling pressures and raised natriuretic peptides (NPs). The accurate diagnosis of HFpEF is even more challenging in patients who are obese, since the echocardiographic imaging quality may be suboptimal, the parameters for the evaluation of cardiac structure are indexed to the body surface area (BSA) and thus may underestimate the severity of the remodeling, and the NPs in patients who are obese have a lower normal threshold. Moreover, patients who are obese are prone to atrial fibrillation (AF) and pulmonary hypertension (PH), making the evaluation of diastolic dysfunction more strenuous. The current review aims to offer insights on the accurate diagnosis of HFpEF in patients who are obese in different clinical scenarios-patients who are obese in different clinical scenarios-such as in sinus rhythm, in atrial fibrillation, and in the case of pulmonary hypertension-by applying multimodality imaging and clinical diagnostic algorithms.

Circulating mitochondrial DNA signature in cardiometabolic patients

BACKGROUND

Mitochondrial dysfunction is a hallmark of cardiometabolic diseases. Circulating mitochondrial DNA (mtDNA) profiles could refine risk stratification, but current methods do not account for different fractions of circulating mtDNA. We investigated whether patients with type 2 diabetes and/or heart failure (HF) have a specific signature of the total circulating mtDNA profile, including intracellular and cell-free fractions.

METHODS

We performed a complete clinical assessment, including blood tests, 12-lead ECG and ultrasound at rest and during cardiopulmonary exercise. Ultrasound congestion was defined at rest as inferior vena cava of ≥ 21 mm, lung B-lines ≥ 4, or discontinuous renal venous flow. In fasting whole blood and plasma samples collected at rest, we simultaneously measured the copy number of the cellular and cell-free components of mtDNA by real-time quantitative polymerase chain reaction (qPCR) using custom standards. We calculated the ratio of cell mtDNA to cell-free mtDNA as an index of mitochondrial efficiency.

RESULTS

We enrolled 120 consecutive patients: 50 (42%) with HF and preserved ejection fraction (HFpEF), 40 (33%) with HF and reduced ejection fraction (HFrEF) and 30 (25%) at risk of developing HF; 42/120 (35%) had diabetes. Cell-free mtDNA was increased in patients with HF (with higher levels in HFrEF than HFpEF) and those with diabetes. Cell-free mtDNA was also higher in patients with systemic inflammation (expressed by high-sensitivity C-reactive protein [hs-CRP] ≥ 0.2 mg/dL with neutrophil-lymphocyte ratio [NLR] > 3) and more ultrasound signs of congestion. The cell/cell-free mtDNA ratio showed opposite trends (all p < 0.05), but there were no significant differences in cell mtDNA. Cell-free mtDNA and mtDNA ratio independently predicted the presence of ≥ 2 ultrasound signs of congestion and effort intolerance (peak oxygen consumption < 16 mL/kg/min) at ROC analysis and using multivariable regressions after adjustment for age, sex, hs-CRP, NLR, high-sensitivity Troponin T and NT-proBNP.

CONCLUSIONS

Patients with HF and diabetes have an altered circulating mtDNA signature characterised by higher cell-free mtDNA and lower mtDNA ratio, whereas cellular mtDNA remains unaffected. Cell-free mtDNA and mtDNA ratio are associated with impaired response to exercise, higher systemic inflammation and increased congestion. Circulating mitochondrial profile could be a new biomarker of mitochondrial status in cardiometabolic diseases.

Serum Albumin-Creatinine Ratio and Anthracycline Cardiotoxicity in Patients with Cancer

Background: Several studies have suggested that the serum albumin-creatinine ratio (sACR) is a useful marker for the early risk stratification of patients with cardiomyocyte injury. This study aims to evaluate the relationship between sACR and anthracycline-related cardiotoxicity. Methods: This study included patients who had received anthracycline-based chemotherapy between 2014 and 2023 and had undergone baseline and follow-up echocardiography after the treatment. The level of sACR was calculated using serum albumin and creatinine values obtained before the chemotherapy. The definition of cardiotoxicity was based on the criteria of the European Society of Cardiology (ESC) for ejection fraction and the American Society of Echocardiography (ASE) for diastolic dysfunction. The patients were categorized into either the high or low sACR group based on the cut-off value obtained from the receiver operating characteristic (ROC) curve analysis. Results: In total, 525 patients (159 males, 366 females) were included. Multivariate analysis after adjustment for age, body mass index (BMI), cardiovascular disease, hemoglobin, anthracycline dose, and gender showed that sACR (HR = 1.85% 95 CI 1.12 to 3.06 p = 0.016), cardiovascular disease (HR = 1.97% 95 CI 1.08 to 3.61 p = 0.027), BMI (HR = 1.86% 95 CI 1.12 to 3.10 p = 0.017), and age (HR = 1.02% 95 CI 1.001 to 1.04 p = 0.036) were significantly associated with an increased risk of cardiotoxicity. Conclusions: This study is the first to show a significant relationship between sACR and cardiotoxicity related to anthracycline use. Routine laboratory tests that are conducted before anthracycline therapy can aid clinicians in identifying high-risk patients who may require closer follow-up or cardioprotective measures.

The role of multi-modality imaging for the assessment of left atrium and left atrial appendage: a clinical consensus statement of the European Association of Cardiovascular Imaging (EACVI), European Heart Rhythm Association (EHRA) of the European Society of Cardiology (ESC)

Structural, architectural, contractile, or electrophysiological alterations may occur in the left atrium (LA). The concept of LA cardiopathy is supported by accumulating scientific evidence demonstrating that LA remodelling has become a cornerstone diagnostic and prognostic marker. The structure and the function of the LA and left atrial appendage (LAA), which is an integral part of the LA, are key elements for a better understanding of multiple clinical conditions, most notably atrial fibrillation, cardioembolism, heart failure, and mitral valve diseases. Rational use of various imaging modalities is key to obtain the relevant clinical information. Accordingly, this clinical consensus document from the European Association of Cardiovascular Imaging, in collaboration with the European Heart Rhythm Association, provides comprehensive, up-to-date, and evidence-based guidance to cardiologists and cardiac imagers for the best practice of imaging LA and LAA for the diagnosis, management, and prognostication of the patients.

Evaluating Right Ventricular Function Using Longitudinal Displacement

Background and Objectives: The right ventricle has a complex, asymmetrical shape, making accurate imaging and functional assessment by echocardiography challenging. Various methods have been proposed for evaluating right ventricular function, each one with its limitations. This study introduces a new method for assessing global and regional right ventricular function using longitudinal displacement. Materials and Methods: We studied 21 healthy young individuals who underwent echocardiographic examinations at our hospital for screening purposes. Speckle-tracking echocardiography was used to analyze their echocardiographic images and measure the longitudinal displacement of the right ventricle. Results: Our findings show that longitudinal displacement is highest in the basal segments and lowest in the apical segments of the right ventricle, demonstrating a "reversed basal-to-apical gradient". Longitudinal strain, on the other hand, was found to be highest at the apex and lowest at the base. We observed a strong correlation between longitudinal displacement and tricuspid annulus plane excursion (TAPSE), with an agreement of 89.47%. Longitudinal displacement over the right ventricle free wall was significantly higher than that over the septum. There was a good agreement between the manual and automatic measurements of right ventricular strain. Conclusions: Longitudinal displacement of the right ventricle can be reliably measured using speckle-tracking-echocardiography. This original measurement provides a "true" assessment of displacement at each right ventricular segment without postprocessing. Unlike TAPSE, which measures tricuspid annular motion, longitudinal segmental displacement offers comprehensive data on all segments at each level and can serve as an additional tool for assessing right ventricular function. The manual assessment of right ventricular strain provides a practical option in appropriate clinical settings.

Impaired Left Atrial Reservoir Strain Causes Exercise-Induced Pulmonary Hypertension in Patients With Preserved Left Ventricular Ejection Fraction

PURPOSE

Exercise-induced pulmonary hypertension (EIPH), assessed using exercise stress echocardiography (ESE), is important in diagnosing early stage of heart failure (HF) with preserved ejection fraction (EF) and affects exercise tolerance and prognosis. Left atrial (LA) reservoir strain, which reflects the left ventricular filling pressure, is an associated factor with HF. This study aimed to investigate the association between the LA reservoir strain at rest and EIPH.

METHODS

This retrospective analysis included 188 participants with a left ventricular EF ≥ 50% who underwent ESE. EIPH was defined as a peak tricuspid regurgitation (TR) pressure gradient >50 mm Hg. HF events (HF hospitalization or diuretic use with brain natriuretic peptide ≥100 pg/mL) were evaluated in patients with ≥3 months follow-up.

RESULTS

Thirty-four (18.1%) patients were diagnosed with EIPH. LA reservoir strain at rest with an optimal cutoff value of 21% identified patients, with 73% sensitivity and 59% specificity. The multivariate logistic regression analysis indicated that LA reservoir strain was independently associated with EIPH. Furthermore, adding LA reservoir strain to the TR-velocity significantly improved EIPH discrimination. During a median follow-up period of 336 days, 29 patients (21.6%) experienced HF events. The hazard ratio for HF events in patients with LA reservoir strain ≤21% was 4.04 after adjusting for age and HFA-PEFF score (95% confidence interval, 1.29-12.7).

CONCLUSION

LA reservoir strain at rest was associated with EIPH and HF events in patients with preserved EF, suggesting that impaired LA reservoir strain could increase the risk of HF.

Electrical Remodeling and Low Voltage Areas in Atrial Fibrillation Patients with Functional Mitral Regurgitation: A Multicenter Evaluation

Background

Atrial fibrosis may act as a substrate for atrial fibrillation (AF) and atrial functional mitral regurgitation (MR); thus, recognition is required to select the optimal therapeutic intervention.

Methods

We examined clinical data from 1045 consecutive patients in three centers who underwent catheter ablation for persistent AF between 2020 and 2022. 75 patients met the moderate and severe MR criteria and completed a 1-year follow-up. Voltage mapping during the ablation procedure was reviewed to classify the extent of atrial fibrosis.

Results

Significant atrial fibrosis was found in 34 patients (45.3%), and these patients had a higher prevalence of congestive heart failure (New York Heart Association (NYHA) II-III: 76.5% vs. 36.6%, p < 0.001) and an increased incidence of biatrial enlargement at baseline than the mild fibrosis group. At the 1-year post-ablation period, the entire cohort exhibited a decrease in left atrial size (41.6 ± 6.5 mm vs. 45.5 ± 5.3 mm, p < 0.001), and a significant reduction in MR was achieved in 70.7% of patients. The significant fibrosis group had a higher recurrence rate of atrial arrhythmias (55.9% vs. 22.0%, log-rank p = 0.002) and no significant change in atria size compared with baseline diameters (left atrium, 44.4 ± 6.4 mm vs. 47.2 ± 5.6 mm, p = 0.068; right atrium, 44.7 ± 11.2 mm vs. 46.7 ± 6.2 mm, p = 0.427).

Conclusions

This study revealed a considerable proportion of significant fibrosis in patients with atrial functional MR and AF, leading to limited effectiveness in reducing atrial size following catheter ablation. Optimal intervention to reduce atrial size and recurrent arrhythmias in this population requires further investigation.

The relation between body mass index and target organ damage and the mediating role of blood pressure

BACKGROUND/OBJECTIVES

The relationship between obesity and blood pressure (BP) is well known, but limited data exists regarding its relationship with target organ damage (TOD). Therefore, this study aimed to examine the relationship between body mass index (BMI) and TOD and the mediating role of BP.

SUBJECTS/METHODS

2555 adults (52.0% women) who visited a local Hypertension Unit with valid measures on weight, height, 24 h ambulatory BP monitoring, office BP measurements, echocardiography, carotid ultrasonography and blood creatinine levels, included in this cross-sectional study. BMI was used to categorize participants as having normal weight (< 25 kg/m2), overweight (25-29.9 kg/m2) or obesity (≥ 30 kg/m2). The intima-media thickness (IMT) of the common (CCA) and the internal (ICA) carotid artery, left ventricular mass (LVM), LVM index (LVMI) and estimated glomerular filtration rate (eGFR) were estimated and used as TOD indices. Linear regression models were used to examine the relationship between obesity and BP measurements or TOD, while structural equation modeling (SEM) for mediation analysis.

RESULTS

Obesity was significantly related to 24-hour systolic BP (b = 3.72, 95%CI: 2.24-5.21, p < 0.001), CCA-IMT (b = 0.04, 95%CI: 0.02-0.05, p < 0.001), ICA-IMT (b = 0.03, 95%CI: 0.01-0.05, p = 0.020), and LVMI (b = 7.54, 95CI%: 4.25-10.83, p < 0.001). The mediation analysis revealed that 24-hour systolic BP mediated by 27.9% the relationship between BMI and CCA-IMT, by 31.3% the relationship between BMI and ICA-IMT, and by 18.1% the relationship between BMI and LVMI.

CONCLUSIONS

These results indicate that obesity is associated with indices of asymptomatic cardiac remodeling and vascular atherosclerosis, and systolic BP mediates these relationships.